Title: Industrial Process Safety Lessons from major accidents and their application in traditional workplace safety and health
1Industrial Process Safety Lessons from major
accidents and their application in traditional
workplace safety and health
Graham D. Creedy, P. Eng, FCIC, FEIC Formerly
Senior Manager, Responsible Care Canadian
Chemical Producers Association (now Chemistry
Industry Association of Canada) gcreedy_at_canadianch
emistry.ca System Safety Society Spring
Event May 26, 2011
2Overview
- How I got into this
- The evolution of the philosophy of industrial
safety and prevention of major accidents - Some key insights and concepts
- How these apply to management of workplace safety
in various sectors and at different levels of the
organization
3Some history
- 1984 Bhopal accident is wake-up call to chemical
industry - Industry responsibility to understand and control
hazards and risks - Responsible Care launched in Canada
- Principles, codes, commitment, tools, support,
progress tracking, verification - Major Industrial Accidents Council of Canada
1987-1999
4Safety Performance by Industry Sector Injuries
illnesses per 200,000 hours worked (2002)
Source US Bureau of Labor Statistics
(www.bls.gov/iif)
5Relative risks of fatal accidents in the work
place of selected occupations
Fishers (as an occupation) 35.1
Timber cutters (as an occupation) 29.7
Airplane pilots (as an occupation) 14.9
Garbage collectors 12.9
Roofers 8.4
Taxi drivers 8.2
Farm occupations 6.5
Protective services (fire fighters, police guards, etc.) 2.7
Average job 1.0
Grocery store employees 0.91
Chemical and allied products 0.81
Finance, insurance and real estate 0.23
Sanders, R.E, J. Hazardous Materials 115 (2004)
p143, citing Toscano (1997)
6Chemistry Industry Association of Canada Member
Performance
CIAC website www.canadianchemistry.ca Staff
contact Stephanie Butler 613-237-6215 x 245
7A proactive approach focuses on these
categories, but be careful you may miss the
really serious ones!
8Terminology
- Process hazard
- A physical situation with potential to cause harm
to people, property or the environment - Risk (acute)
- probability x consequences of an undesired event
occurring
9They thought they were safe
- Good companies can be lulled into a false sense
of security by their performance in personal
safety and health - They may not realise how vulnerable they are to a
major accident until it happens - Subsequent investigations typically show that
there were multiple causes, and many of these
were known long before the event
BP Deepwater Horizon
10Why and how defences fail
- People often assume systems work as intended,
despite warning signs - Examples of good performance are cited as
representing the whole, while poor ones are
overlooked or soon forgotten - Analysis of failure modes and effects should
include human and organizational aspects as well
as equipment, physical and IT systems
11- Process safety management
- Recognition of seriousness of consequences and
mechanisms of causation lead to focus on the
process rather than the individual worker - Many of the key decisions influencing safety may
be beyond the control of the worker or even the
site they may be made by people at another
site, country or organization - Causes differ from those for personnel safety
- Need to look at the whole materials, equipment
and systems and consider individuals and
procedures as part of the system - Management system approach for control
Flixborough, Bhopal, Pasadena
12Scope (elements of process safety management)
- Accountability
- Process Knowledge and Documentation
- Capital Project Review and Design Procedures
- Process Risk Management
- Management of Change
- Process and Equipment Integrity
- Human Factors
- Training and Performance
- Incident Investigation
- Company Standards, Codes and Regulations
- Audits and Corrective Actions
- Enhancement of Process Safety Knowledge
CCPS Guidelines for Technical Management of
Chemical Process Safety
13Functions of a management system
Planning Organizing
Leadership
Controlling Implementing
Direction
Measurement
Structure
Results
CCPS Guidelines for Technical Management of
Chemical Process Safety
14Features and characteristics of a management
system for process safety
Planning Explicit goals and objectives Well-defined scope Clear-cut desired outputs Consideration of alternative achievement mechanisms Well-defined inputs and resource requirements Identification of needed tools and training Organizing Strong sponsorship Clear lines of authority Explicit assignments of roles and responsibilities Formal procedures Internal coordination and communication
Implementing Detailed work plans Specific milestones for accomplishments Initiating mechanisms Controlling Performance standards and measurement methods Checks and balances Performance measurement and reporting Internal reviews Variance procedures Audit mechanisms Corrective action mechanisms Procedure renewal and reauthorization
CCPS Guidelines for Technical Management of
Chemical Process Safety
15Examples of PSM management systems concerns at
different organizational levels
CCPS Guidelines for Technical Management of
Chemical Process Safety
16A page from the Site Self-Assessment Tool
17Use of self-assessment tool for collective
progress reporting and actionAs of August 29,
2008 compared with past five years (some site
changes)Target for meeting Essential level
June 30, 2003
18Process-Related Incident Measure (PRIM) 2007
Findings All Elements
19Assessing an organizations safety effectiveness
- What is the safety policy and culture (written,
unwritten)? - How are the following handled?
- Establishing what has to be done
- Benchmarking
- Communicating
- Assigning accountabilities
- Ensuring that it gets done
- Monitoring and corrective action
- Evidence (documentation) and audit process
- Resourcing not only for ideal but for
anticipated conditions - Balancing with other priorities
- How are exceptions handled?
20Consider targets in groups
- Those who
- Dont care
- Dont know (and perhaps dont know that they
dont know) - Did know, but may have forgotten or could have
gaps in application (and perhaps dont realize
it)
21- Excellent guidance exists but how is it being
used?
22The New Product Introduction Curve
- Can be applied to adoption of new ideas
- Categories differ by ability and more
importantly, motivation
23Accountability
- Management commitment at all levels
- Status of process safety compared to other
organizational objectives such as output, quality
and cost - Objectives must be supported by appropriate
resources - Be accessible for guidance, communicate and lead
24Management of Change
- Change of process technology
- Change of facility
- Organizational changes
- Variance procedures
- Permanent changes
- Temporary changes
25Process and Equipment Integrity
- Design to handle all anticipated conditions, not
just ideal or typical ones - Make sure what you get is what you designed
(construction, installation) - Test to make sure the design is indeed valid
- Make sure it stays that way
- Preventative maintenance
- Ongoing maintenance
- Review
- Be especially careful of automatic safeguards
26- Consider operator as fallible human performing
tasks in background - Design for error tolerance, not just prevention
- detection
- correction
Buncefield, UK
27- Realization of significance of sociocultural
factors in human thought processes and hence in
behaviours
28Human behaviour aspects
Familiarity to engineers More
- People, and most organizations, dont intend to
get hurt (have accidents) - To understand why they do leads us eventually
into understanding human behaviour, both at the
individual and organizational level, and
involves - Physical interface
- Ergonomics
- Psychological interface
- Perception, decision-making, control actions
- Human thought processes
- Basis for reaching decisions
- Ideal versus actual behaviour
- Social psychology
- Relationships with others
- Organizational behaviour
Less
29Human behaviour modes
- Instead of looking at the ways in which people
can fail, look at how they function normally - Skill-based
- Rapid responses to internal states with only
occasional attention to external info to check
that events are going according to plan - Often starts out as rule-based
- Rule-based
- IF, THEN
- Rules need not make sense they only need to
work, and one has to know the conditions under
which a particular rule applies - Knowledge-based
- Used when no rules apply but some appropriate
action must be found - Slowest, but most flexible
30Reasons Cheese Model James Reason,
presentation to Eurocontrol 2004
31Active and latent failures
- Active
- Immediately adverse effect
- Similar to unsafe act
- Latent
- Effect may not be noticeable for some time, if at
all - Similar to resident pathogen. Unforeseen
trigger conditions could activate the pathogens
and defences could be undermined or unexpectedly
outflanked
32A Classic Example of a Latent Failure
- Hazard of material known, but lack of awareness
of potential system failure mode leads to
defective procedure design through management
decision
Epichlorhydrin fire, Avonmouth, UK
33And another
Danvers, MA, Nov 2006 Solvent explosion at
printing ink factory
- Hazards known, but defences compromised by
apparently benign change - Latent error in procedure design creates
vulnerability to likely execution error
US Chemical Safety Board
34And another
- Hazard of material not obvious (despite history)
- Latent error allowed dust to accumulate, creating
conditions for subsequent events
Scottsbluff, NE 1996
Port Wentworth, GA 2007
35Lessons from other fields
- Aerospace and nuclear show how significant human
and organizational aspects can be even where the
obvious signs of failure are technical in nature - Finance shows
- Relevance of such factors without technical
distractions - How fast a system can deteriorate once controls
are relaxed - How wrong risk assessments can influence bad
policy decisions
36Relevance of organizational factors
- The relevance of organizational factors has
also been graphically and tragically revealed in
the inquiry reports of recent UK transportation
and offshore oil disasters. - Prior to ..., senior managers in all the
organizations propounded the pre-eminence of
safety. They believed in the efficacy of the
regulatory system, in the adequacy of their
existing programs, and in their confidence of the
skills and motivation of their staff. - The inquiry reports reveal that their belief in
safety was a mirage, their systems inadequate,
and operator errors and violations commonplace. - The inquiry reports stated that ultimate
responsibility lay with complacent directors and
managers who had failed to ensure that their good
intentions were translated into a practical and
monitored reality. Moreover, the weaknesses so
starkly revealed were not matters of substantial
concern to the regulatory authorities before the
accidents.
HSC, 1993
37Factors that can influence likelihood of failure
- Organizational culture
- the way we do things around here when no-one
is looking - increasingly being recognized as one of the most
important factors in major accidents - perceived balance between output, cost and safety
is heavily dependent on this culture, and
influences whether personnel work in a certain
way because they believe the company and their
co-workers feel it is the right way to do things,
or whether they are simply going through the
motions.
38In general, safety gets better as society learns
more
Standard of Safety
Time
39But the rate of improvement is not steady
Standard of Safety
x 10
Time
40In fact, the curve can be one of periodic rapid
gains followed by gradual but increasing declines
Note how the rate of decay can be expected to
increase due to normalization of deviance
Standard of Safety
x 100
Time
41Organizational Culture Model James W. Bayer,
Senior VP Mfg, Lyondell Chemical Company
Strong
Tribal
Operational Excellence
People
Chaotic
Bureaucratic
Weak
Strong
Systems
42Preservation or loss of corporate memory
- Demographic effects
- Less staff
- Experienced cohort leaving or left
- Skills transfer senior gt (middle) gt junior
- Replacements understand the way something is
done, but not why it is done that way, the
potential consequences of doing it differently
and how to detect and recover from undesired
actions - We are starting to see lowered standards of
design and supervision that fifteen years ago
would have been unthinkable in the chemical
industry (Challenger, 2004)
43- What does an organizations investigation of its
failures reveal about its - Culture
- Management system?
44- Knowledge
- Never realized problem could occur (benchmarking
error) - was it treated as a unique deficiency?
- was there a broader review of the benchmarking
process to find if there are other areas where
knowledge could be deficient? - Policy
- Thought situation would be acceptable but didnt
realize full implications until it happened - Does it appear to be acceptable now?
- Was review of policy and accountability limited
or broad in scope? - System design
- Even if everything had been done as intended,
problem would still have occurred - How comprehensive was analysis of system
deficiencies and practicality of solutions? - How effective is action plan and follow through?
- Was review of system design limited or broad in
scope? - System execution (management system error)
- Problem occurred because someone or something did
not perform as intended - Did analysis consider why execution not as
intended? - Was corrective action appropriate and balanced?
- Was review of system execution limited or broad
in scope?
45Dealing with a Safety (or Engineering) Problem
- Finding out who youre dealing with
- Where is the organization on the curve?
(generally, and re the specific issue or problem) - Where are the people youre dealing with on the
curve? (generally, and re the issue or problem) - Finding out what to do
- Benchmark dont try to reinvent the wheel
unless youre sure there isnt one already (or
youve time and its fun to do so) - Find out what others are doing about it
- Read the instructions
- Identify/define the issue
- If its likely to be regulated, check with
government agencies, trade associations, web,
internet - If not regulated but likely good industry
practice, check suppliers, other users of same
material or item, other users of similar items,
other industry contacts but test the info!!!
(cross-check, ask if it makes sense) - Check standard reference works, (Lees, CCPS, etc)
- Doing it
- Try to think of all situations that are likely to
occur (process, eqpt, people) - KISS, keep it user-friendly, show basis for
decisions if practical to do so - Follow up afterwards to see how its working
46Questions?